Care Unit In Stable Condition Research Articles

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Atrial Embolization after a Transcatheter Mitral Valve Replacement

Atrial Embolization after a Transcatheter Mitral Valve Replacement

An “Ice Cream Headache” in a Term Gravida: A Case Report

BACKGROUND: Headache is often the only presenting symptom of subarachnoid hemorrhage. Its incidence in pregnancy of 5 per 100,000 is dwarfed by more common, benign causes of headache, complicating diagnosis. CASE: We presented a 41 year old at 38 weeks 5 days gestational age that presented local hospital reporting a “terrible brain freeze” after eating ice cream. After transfer of care to a tertiary care center a non-contrast computed tomography scan revealed subarachnoid blood layering in the basal cistern suspicious for sequelae of aneurysm rupture. After a cesarean section was performed the patient was transported to the interventional radiology suite where rupture of a 3mm left paraopthalmic artery aneurysm was confirmed and coiled. A non-ruptured 4mm right paraopthalmic artery aneurysm was also diagnosed. The patient was moved to the Intensive Care Unit in stable condition following the procedures and was discharged post-op day 7. She returned one month later for coiling of the right paraopthalmic artery. CONCLUSION: Headaches during pregnancy can indicate a variety of disease processes. Subarachnoid hemorrhage has high morbidity and mortality for mother and fetus making prompt diagnosis and treatment crucial. This case highlights the safety and importance of prompt cranial imaging in pregnancy when clinically appropriate.

External Iliac Vein Transection Mimicking Phlegmasia Cerulea Dolens After Total Hip Arthroplasty

Iatrogenic venous injury during orthopedic procedures is a well-described phenomenon and carries an 18% perioperative mortality in the literature. These potentially catastrophic complications are usually identified in the operating room and addressed during the index procedure. We present a case of an external iliac vein transection during a total hip arthroplasty that resulted in a presentation similar to phlegmasia cerulea dolens with severe hemorrhagic shock. This is a case report and review of the literature. A 60-year old man with history of bilateral total hip arthroplasty presented for elective revision of his left hip replacement. The procedure was reported to go fine without any intraoperative events noted, and the patient was taken to the postanesthesia care unit in stable condition. While in the postanesthesia care unit, he developed a painful, cyanotic left lower extremity and progressive motor and sensory loss up to the level of the thigh. Duplex ultrasound revealed noncompressible deep veins in the thigh and calf. He was started on a heparin drip and taken emergently to the operating room for presumed phlegmasia cerulea dolens. He has an inferior vena cava filter placed, and left leg venography revealed an external iliac vein transection with extravasation into the pelvis. At this time, he developed circulatory collapse, and his abdomen was increasing in size. A diagnosis of abdominal compartment syndrome was made, and he had an emergency laparotomy, ligation of the left external iliac vein, and four-compartment fasciotomy of the left leg. After this, he was taken to the intensive care unit in critical condition. During the next 48 hours, he began to undergo diuresis and was extubated. Today is he doing well with his abdomen closed, and he regained motor function and sensation in his left leg. A high index of suspicion should be maintained after pelvic orthopedic procedures if there is concern for a vascular complication. Venous injuries are uncommon but can result in significant morbidity and mortality. Prompt diagnosis and surgical treatment are needed to have a favorable outcome.

Inhaled Iloprost for Chronic Thromboembolic Pulmonary Hypertension (CTEPH) During Pregnancy: A Case Report

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subset of pulmonary hypertension caused by acute and recurrent pulmonary emboli. Pulmonary thromboendarterectomy is the treatment of choice, but 10-50% of patients are ineligible for this procedure. We describe the case of a 25-year-old, morbidly obese (228-kg, body mass index 83.5 kg/m(2) ) pregnant woman (G3 P2 ) who presented at 24 weeks' gestation; bilateral pulmonary angiography revealed filling defects and confirmed the diagnosis of CTEPH. The patient was evaluated and deemed to present too high of a risk for pulmonary thromboendarterectomy, so a multidisciplinary team initiated medical therapy. Sildenafil 20 mg orally 3 times/day was started at week 24 of gestation, and inhaled iloprost was added at 26 weeks and titrated to 5 µg inhaled every 2 hrs in order to optimize hemodynamic status prior to a cesarean section delivery scheduled to be performed 6 weeks later. At 32 weeks of gestation, the patient's pulmonary arterial systolic pressure was 77 mm Hg, right atrial pressure was 15 mm Hg, and pulmonary capillary wedge pressure of 16 mm Hg, and a healthy 1741-g male infant was delivered by cesarean section. The patient was transferred back to the medical intensive care unit in stable condition and discharged home 9 days following the procedure. Pharmacotherapeutic strategies for patients with CTEPH who become pregnant are limited to phosphodiesterase type 5 inhibitors and prostacyclin analog therapies due to the teratogenicity of the other drug classes used to treat the disorder (endothelin receptor antagonists and soluble guanylate cyclase stimulators). To our knowledge, this is the first case report of inhaled iloprost use in addition to oral sildenafil to improve patient symptomatology and hemodynamics during the peripartum period of a young pregnant patient with inoperable CTEPH. This drug therapy was used safely, with no noted adverse effects to the newborn or to the patient.

Clot in Bovine Arch Diagnosed by Transesophageal Echocardiography

Clot in Bovine Arch Diagnosed by Transesophageal Echocardiography

OB Hemorrhage Complicated by DIC: Are You Ready?

Childbearing Poster Presentation Background This presentation addresses the management of a patient admitted to Baylor University Medical Center's labor and delivery sustaining massive hemorrhage with resulting disseminated intravascular coagulation (DIC) and peripartum hysterectomy after an induction of labor and forceps assisted vaginal delivery. Prompt recognition, timely intervention, and a collaborative multidisciplinary team approach were required to save this patient's life. Case A 35‐year‐old healthy female, primigravida at 40 1/7 weeks gestation was admitted for oxytocin induction of labor. The patient required a low forceps assisted vaginal delivery for persistent occiput posterior position and delivered a healthy male, weighing 8lb 7oz. Following the repair of a third‐degree midline episiotomy and bilateral sidewall lacerations, the patient had an initial estimated blood loss of 800 ml, with a firm fundus and vaginal packing left in place for a noted friable posterior wall. Over the next hour, after the vaginal packing was placed, the patient's mean arterial pressure showed a significant drop from 89 on admission to 52. Fluid resuscitation was initiated utilizing Lactated Ringer's solution and Hespan, and 2.5 mg of Methergine was administered. Continued bleeding was noted and the patient was taken to the operating room (OR) for further evaluation. A stat hematocrit was 16.6; the patient's starting hematocrit was 32.3. In the OR, the patient was noted to have further deteriorating vital signs and oozing was noted from previous puncture sites. The patient was intubated by anesthesia. Lab work from a hemostasis profile revealed DIC. For the next 2 hours extensive resuscitation with cryoprecipitate, fresh frozen plasma, blood, and platelets were administered in an attempt to correct the DIC, preserve the patient's uterus, and return her to a hemostatic state. Continued bleeding was noted and the decision was made by the physician to proceed with a hysterectomy. Following hysterectomy, the patient was transferred to the intensive care unit in stable condition. Conclusion Massive hemorrhage is a leading cause of maternal death. Prompt recognition, timely, effective communication, and rapid response are crucial for positive outcomes. Case review and debriefing led to quality action items being identified. Simulation training has played a key role in quality improvement initiatives. The ability to activate a massive transfusion protocol was crucial in the above case. Simulation scenarios and in situ drills have been developed through which multidisciplinary collaboration allows identification and improvement in processes without harm to patients.

Bilateral Brachial Plexus Home Going Catheters After Digital Amputation for Patient With Upper Extremity Digital Gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay.KeywordsBrachial plexus; Home going catheters; Post-operative pain

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the TableT1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 17-year-old G1P0 is admitted to labor and delivery at term for borderline low amniotic fluid that was discovered at a routine prenatal visit. The patient has a medical history of panic attacks, has no known drug allergies, and reports prenatal vitamins as her only medication during pregnancy. Prenatal laboratory results are within normal limits. Vaginal examination upon admission reveals a cervix dilated 1 cm with an elevated presenting part. A cervical ripening agent followed by oxytocin induction is planned to achieve delivery. A fetal tracing is obtained at the time of insertion of the cervical ripening agent (misoprostol 25 mcg) per vagina (Fig. 1).Findings on EFM Strip #1 are: Five hours later, vaginal examination reveals that the cervix is unchanged. A repeat dose of misoprostol is administered and another tracing is obtained (Fig. 2).Findings on EFT Strip #2 are: Six hours after the last dose of misoprostol, oxytocin augmentation is started. See Figure 3 for the tracing at that time.Findings on EFM Strip #3 are: Three hours later, the cervix has dilated to 3 cm and the presenting part is now at a −2 station. The patient continues to receive a low amount of oxytocin as another fetal tracing is obtained (Fig. 4).Findings on EFM Strip #4 are: Two and a half hours later, an epidural is administered for pain management. Forty minutes later, artificial rupture of membranes is attempted, but no fluid is noted. The fetal tracing obtained at that time is shown in Figure 5.Findings on EFM Strip #5 are: One hour later, an amnioinfusion is started and an intrauterine pressure catheter is placed to measure uterine contractions. The cervix is dilated 3 to 4 cm and 80% effaced, with the station of the presenting part unchanged. One hour after initiation of the amnioinfusion, another tracing is obtained (Fig. 6).Findings on EFM Strip #6 are: Forty minutes later, the physician attempts both scalp stimulation and VAS (Fig. 7).Findings on EFM Strip #7 are: The findings are reviewed with the patient and her family, and a joint decision is made for an emergent cesarean delivery. A viable female infant is delivered approximately 15 minutes later with Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. The infant weighs 7 lb 5 oz. Thick meconium is noted. Umbilical cord gases are obtained, and the infant is admitted to the neonatal intensive care unit in stable condition for observationT2.

Aortic Valve Replacement for Aortic Stenosis During Orthotopic Cardiac Transplant

Although concomitant coronary bypass, and mitral and tricuspid valve surgery have been used to expand the donor pool for cardiac transplantation, aortic valve disease is considered an absolute contraindication for use of an offered organ. A case is presented with the successful use of an organ requiring concomitant aortic valve replacement for calcific aortic stenosis on a congenitally bicuspid valve. Eighteen-month follow-up documented excellent allograft function with a normally functioning mechanical aortic prosthesis. Aortic valve disease in offered organs can be successfully treated with aortic valve replacement at the time of transplantation and should not preclude the use of the organ in the setting of a recipient who is a candidate for a marginal allograft.

Postoperative Hyperthermia, Rhabdomyolysis, Critical Temperature, and Death in a Former Premature Infant After His Ninth General Anesthetic

An 8-mo-old infant born at 24-wk of gestation died unexpectedly 12 h after his ninth uneventful general anesthetic. Preoperatively, he required low-flow nasal oxygen due to bronchopulmonary dysplasia, chronic diuretic therapy, and IV alimentation. As planned preoperatively, the infant remained tracheally intubated after his elective surgery and went to the Neonatal Intensive Care Unit in stable condition. However, over the next 6 h, he developed fever. The diagnosis of postoperative sepsis was considered. One hour before his death his temperature reached 43 degrees C. Autopsy documented Duchenne's muscular dystrophy and renal tubules containing myoglobin.

Single-Lung Ventilation for Right-Sleeve Pneumonectomy With a Modified Nasal RAE Endotracheal Tube

Single-Lung Ventilation for Right-Sleeve Pneumonectomy With a Modified Nasal RAE Endotracheal Tube

The frozen elephant trunk: An interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta

The treatment of complex aortic pathologies involving the ascending aorta, the aortic arch, and the descending aorta remains a challenging issue in aortic surgery. The frozen elephant trunk procedure effectively combines surgical and interventional technologies in the treatment of extensive aortic aneurysms and dissections. We present two patients with complex aortic lesions involving all three segments of the thoracic aorta. The device used in our series is the new E-vita open hybrid prosthesis consisting of a proximal woven polyester tube and a distal self-expandable nitinol stent graft, which can be delivered antegrade into the descending aorta.

Anestesia para implante de marca-passo em paciente adulto com ventrículo único não-operado: relato de caso

JUSTIFICATIVA E OBJETIVOS: Ventrículo único é anormalidade rara encontrada em cerca de 1% dos pacientes com cardiopatia congênita. Somente 11 casos de pacientes com ventrículo único não-operado e idade acima de 50 anos foram relatados na literatura. Este trabalho teve como objetivo descrever a conduta anestésica em paciente com ventrículo único para implante de marca-passo. RELATO DO CASO: Paciente do sexo feminino, 47 anos, com presença de dupla via de entrada do ventrículo esquerdo, L-transposição de grandes artérias e estenose subpulmonar, sem correção cirúrgica prévia, foi agendada para implante de marca-passo cardíaco definitivo seqüencial de duas câmaras. Ao MAPA apresentava bloqueio atrioventricular de segundo grau e uma freqüência cardíaca média de 45 bpm. Os exames pré-operatórios mostravam hematócrito de 57%, coagulograma normal, função ventricular preservada. A monitorização constou de oxímetro de pulso, ECG nas derivações D II e V5, PIA, capnógrafo e analisador de gases. Um marca-passo temporário transcutâneo foi disponibilizado no caso de bradicardia intensa. A anestesia foi induzida com fentanil (0,25 mg), etomidato (20 mg) e atracúrio (35 mg). Quatro minutos após a indução, a freqüência cardíaca diminuiu para 30 bpm, sendo administrado 1 mg de atropina, com reversão da bradicardia. A anestesia foi mantida com sevoflurano a 2,5%, ar 60% e oxigênio 40%. O estado hemodinâmico e a saturação de oxigênio permaneceram estáveis. A paciente foi encaminhada à unidade de terapia intensiva estável e extubada ao final do procedimento. CONCLUSÕES: A conduta anestésica para implante de marca-passo em paciente de 47 anos com dupla via de entrada do ventrículo esquerdo e estenose subpulmonar não-operada foi adequada, haja vista que permitiu a realização do procedimento indicado.

Limitations of diffusion-weighted imaging in distinguishing between a brain tumor and a central nervous system histoplasmoma

A 46-year-old African-American male presented to the hospital with a four-month history of progressive headache, left-sided weakness, and double vision. His past medical history was otherwise unremarkable, and he denied any recent history of fever, chills, respiratory symptoms, or systemic illness. He reported a history of intravenous drug use and having snorted cocaine within the past 12 months. On examination he had dysarthric speech, a partial right cranial nerve III palsy, and mild left hemiparesis (arm and leg). The remainder of his neurological examination was unremarkable. MRI of the head revealed a 2-cm ring-enhancing mass in the right pons (Figure 1). The mass had very low signal on T2-weighted images, and there was no evidence of reduced diffusion on diffusion-weighted imaging (DWI) (1.5 Tesla clinical scanner, single-shot echo-planar, diffusion gradient 0 and 1000 s/mm, acquired in three orthogonal directions). The apparent diffusion coefficient (ADC) of the mass ranged from 1.2 10 mm/s to 1.7 10 mm/s. Moderate T2 prolongation was noted in the pons, extending into the bilateral cerebellar hemispheres and superiorly into the right midbrain. The mass was presumed to be neoplastic based on the imaging findings, and workup for a systemic primary neoplasm was initiated. An open biopsy of the pontine mass was obtained through a right frontotemporal craniotomy with zygomatic osteotomy with image guidance. The lesion was extremely firm, and specimens sent for KOH preparation and frozen section demonstrated yeast. Additional specimens were sent for permanent section and culture. Having obtained a diagnosis, the wound was closed, and the patient was returned to the intensive care unit in stable condition. Amphotericin B therapy was initiated. Results of HIV testing, completed in the postoperative period, were positive, and his CD4 count was 10/ll. Permanent section pathology showed chronic inflammation with associated necrosis and fungal organisms (Figure 2). Biopsy culture grew Histoplasma capsulatum and was confirmed using a DNA probe. He was treated with a two-week course of amphotericin B, followed by a 10week course of IV itraconazole. He was then started on lifetime maintenance oral itraconazole. Highly active antiretroviral therapy (HAART) was initiated after four weeks of itraconazole therapy. DWI is an MRI-based technique that measures the random translational mobility of water molecules, also known as Brownian motion. The more the movement of water is restricted in a tissue, the higher the DWI signal intensity and the lower the ADC. DWI has been applied to multiple disease processes, including ring-enhancing intraparenchymal brain masses. Two of the main differential considerations in the setting of a ring-enhancing intraparenchymal brain lesion are abscess and necrotic tumor. Distinguishing these two lesions on conventional imaging is often

Recombinant Factor VIIa for Refractory Bleeding After Cardiac Surgery Secondary to Anticoagulation with the Direct Thrombin Inhibitor Lepirudin

A 56-year-old man with heparin-induced thrombocytopenia with thrombosis syndrome (HITTS) received anticoagulation with recombinant hirudin (lepirudin) for emergency coronary artery bypass graft (CABG) surgery and aortic valve replacement. The patient experienced life-threatening refractory bleeding that was successfully treated with recombinant factor VIIa. He had a history of infective endocarditis that resulted in severe aortic insufficiency, three-vessel coronary artery disease, and acute renal failure requiring hemodialysis. The patient was transferred from another hospital for the emergency surgery, but before his transfer, he developed HITTS secondary to therapeutic heparin for a deep vein thrombosis of the lower extremity. The presence of HITTS, the urgent nature of the case, and the availability of the direct thrombin inhibitor led the surgical team to select lepirudin for anticoagulation to facilitate cardiopulmonary bypass. After separation from cardiopulmonary bypass, the patient was in a coagulopathic state due to the inability to reverse the lepirudin and the slowed elimination of the drug secondary to inadequate renal function. As a result, the patient experienced excessive generalized oozing that was unresponsive to traditional therapies and blood product transfusions. Recombinant factor VIIa 35 microg/kg was given as rescue therapy. The bleeding slowed, which allowed placement of chest tubes and closing of the sternum. The patient was transferred to the intensive care unit in stable condition with no evidence of thrombosis in the freshly placed bypass grafts or on the bioprosthetic valve. Recombinant factor VIIa appears to be a suitable option as salvage therapy in patients with refractory bleeding secondary to anticoagulation with a direct thrombin inhibitor during cardiac surgery.

Hemodynamic Instability After Cardiac Surgery: Transesophageal Echocardiographic Diagnosis of a Localized Pericardial Tamponade

A case of a 76-year-old woman with a history of ischemic heart disease and chronic mitral valve regurgitation is presented. Her preoperative transthoracic echocardiogram (TTE) showed moderate-to-severe mitral regurgitation, moderate tricuspid regurgitation with pulmonary hypertension (pulmonary artery pressure 50 mmHg), and moderately depressed left ventricular systolic function (ejection fraction 43%). She underwent elective surgery for coronary artery bypass grafting and valve repair. She received a left internal thoracic artery graft to the left anterior descending artery, an annuloplasty ring (Carpentier Physio size 28 mm; Edwards Lifesciences, Irvine, CA) plus a quadrangular resection of the posterior leaflet of the mitral valve, and an annuloplasty ring (Edwards Mc3 size 32 mm) to the tricuspid valve. Routine surgery was performed, with closure of the pericardium and placement of 2 mediastinal and 2 pleural drains. The intraoperative course was uneventful. At the end of surgery, she was transferred to the intensive care unit in stable condition with dopamine and nitrates. In the subsequent hours, her hemodynamics showed an adequate systolic arterial pressure (110 mmHg), normal-to-high heart rate (95 beats/min), and central venous pressure (13 mmHg). Metabolic acidosis, with elevated blood lactate, and gas exchange impairment developed. A pulmonary artery catheter was placed, which revealed a severely reduced cardiac index (1.3 L/min/m2) and mixed venous oxygen saturation (43%); pulmonary artery occlusion pressure (13 mmHg) and pulmonary arterial pressure (32/10 mmHg) were both normal. Central venous pressure values were confirmed as previously assessed from the central venous catheter (13 mmHg). A TTE was performed; it confirmed the reduced systolic function of the left ventricle, no mitral valve regurgitation, mild residual tricuspid regurgitation, and no evidence of pericardial effusion. Because of the unclear hemodynamic data interpretation, a TEE was obtained that revealed a large clot (3.5 5.2 cm) localized in the pericardial cavity around the right atrium at the base of the heart (Fig 1). This caused a localized pericardial tamponade, partially obliterating the right atrium during diastole. The patient went back to the operating room to undergo a surgical revision and hemostasis of the pericardial space. The presence of a large clot (250 mL) was confirmed, and prompt evacuation led to an immediate improvement in hemodynamic function. The patient was transferred back to the intensive care unit in stable condition and subsequently recovered uneventfully.

Successful Fontan procedure for asplenia with pulmonary atresia and major aortopulmonary collateral arteries

Asplenia with a single ventricle and major aortopulmonary collateral arteries (MAPCAs) is a rare congenital cardiac anomaly. In this patient group achievement of the Fontan procedure depends on ample rehabilitation of the pulmonary arteries to secure sufficient pulmonary vascular beds and the prevention of progressive pulmonary vascular obstructive disease. Here we report a successful 1-stage bilateral unifocalization of the pulmonary blood supply followed by a staged Fontan procedure in a patient with a univentricular heart and MAPCAs. Clinical Summary The patient was given a diagnosis of asplenia, univentricular heart (right ventricular type), common atrioventricular orifice, pulmonary atresia, bilateral superior vena cavas, total anomalous pulmonary venous connection (intracardiac type), and MAPCAs on the basis of echocardiography and cardiac catheterization. His neonatal aortography showed a small central pulmonary artery (3 mm in diameter) and bilateral multiple MAPCAs (Figure 1, A). The patient’s arterial oxygen saturation (Sa O2) was around 80%, and his pulmonary/systemic blood flow ratio (Qp/Qs) was 1.6 with stable hemodynamics. Subsequent cardiac catheterization at 6 month of age revealed a good-sized central pulmonary artery (Figure 1, B) and 5 large MAPCAs. His SaO2 was approximately 87%, and his Qp/Qs had increased to 3.7. At 1 year of age, he underwent a primary complete unifocalization of his bilateral pulmonary arteries, total anomalous pulmonary venous connection repair for progressive pulmonary venous obstruction (Figure 2), and a left modified Blalock-Taussig shunt (polytetrafluoroethylene [PTFE],* 5 mm). The postoperative course was uneventful except for transient bilateral phrenic nerve palsy. He subsequently did well, while becoming increasingly cyanotic. A catheterization at 2 years of age revealed peripheral pulmonary stenosis, low pulmonary vascular resistance (1.2 Wood units), and normal pulmonary blood flow (Qp/Qs 1.0). The patient then underwent a bilateral bidirectional cavopulmonary shunt and take down of his left modified Blalock-Taussig shunt without cardiopulmonary bypass. This postoperative course was also uneventful, with an SaO2 of 85% and superior vena caval pressure of 10 mm Hg. Eight months after the bilateral bidirectional cavopulmonary shunt, a cardiac catheterization was performed, demonstrating good-shaped pulmonary arteries (Figure 3), low pulmonary vascular resistance (1.4 R*U), low pulmonary artery pressure (mean, 10 mm Hg), and low pulmonary blood flow (Qp/Qs 0.8). Two weeks before definitive surgical intervention, he underwent balloon angioplasty for peripheral pulmonary stenoses and coil embolization of aortopulmonary collateral arteries. At 3 years of age, a fenestrated modified Fontan procedure was performed. An 18-mm PTFE tube graft with a 4-mm PTFE tube graft anastomosed in end-to-side fashion was used for the extracardiac total cavopulmonary connection. The 4-mm PTFE tube graft was anastomosed to the common atrium as a fenestration. The patient was hemodynamically stable intraoperatively, with superior vena caval and inferior vena caval pressures of 11 mm Hg, a common atrial pressure of 4 mm Hg, and an SaO2 of 94%. The patient returned to the cardiovascular intensive care unit in stable condition and was extubated 3 hours after the operation. His postoperative course was uneventful. He was transferred to the general ward on the first postoperative day and discharged home 13 days later without any complications. Three months after the Fontan procedure, another cardiac catheterization was performed, demonstrating a spontaneously occluded tube graft fenestration, an Sa O2 of 96%, low pulmonary artery pressure (mean, 12 mm Hg), and excellent Fontan circulation.

Amiodarone for atrial fibrillation during off-pump coronary artery bypass graft surgery

Case 1 An 81-year-old woman presented for OP-CAB surgery with severe 3-vessel coronary artery disease. Significant components of her past medical history included a diagnosis of mitral valve prolapse and 3 separate transient ischemic attacks that were believed to be related to the mitral valve dysfunction. Preoperative medications included metoprolol and enteric-coated acetylsalicylic acid. An intraoperative transesophageal echocardiogram revealed a left ventricular ejection fraction of 35% and moderate left atrial enlargement without evidence of thrombus. Shortly after opening the pericardium, the patient was noted to convert from sinus rhythm to atrial fibrillation. With this change in rhythm, the ventricular rate increased from 80 to 120 beats/min, and systolic blood pressure decreased from 125 to 90 mmHg. Synchronized electrical cardioversion was attempted 4 times without effect. A loading dose of 300 mg of amiodarone (patient’s weight, 49 kg) was administered intravenously over 30 minutes while the proximal vein graft anastomoses to the aorta were completed. During the amiodarone infusion, the patient’s ventricular rate slowed to 70 beats/min, and phenylephrine was administered for a mild transient decrease in blood pressure. After completion of the loading dose, the patient was electrically cardioverted to sinus rhythm on the first attempt. The patient then underwent 4 distal coronary artery anastomoses without further incident. An amiodarone infusion was initiated after the loading dose and continued for 24 hours. The patient’s recovery proceeded uneventfully, and no further arrhythmias had occurred at the time of discharge on postoperative day 7. Case 2 A 78-year-old man presented for OP-CAB surgery for treatment of 3-vessel coronary artery disease. The patient’s past medical history included non‐insulin-dependent diabetes, a remote stroke from which he had recovered, and cholelithiasis. Preoperative medications included glipizide, acetylsalicylic acid, atorvastatin, and amlodipine. A preoperative transthoracic echocardiogram was essentially normal with the exception of impaired left ventricular relaxation. The patient’s hospital course was remarkable for the development of acute cholecystitis requiring percutaneous cholecystostomy 7 days before OP-CAB surgery. At that time, the patient was noted to suffer a self-limited episode of atrial fibrillation lasting 1 hour. Atrial fibrillation recurred intraoperatively during inspection of the epicardial vessels. A loading dose of 450 mg of amiodarone (patient’s weight, 98 kg) was administered intravenously over 30 minutes without hemodynamic effect. After amiodarone loading, the patient was successfully electrically cardioverted to sinus rhythm. A 3-vessel OP-CAB procedure was completed, and the patient was transferred to the intensive care unit in stable condition. No further amiodarone was administered after the loading dose, and no further episodes of atrial fibrillation were noted during the patient’s hospital stay. An open cholecystectomy was performed on postoperative day 15, and the patient was discharged to a rehabilitation facility 21 days after his cardiac surgery. Case 3

Explicit Intraoperative Recall at a Bispectral Index of 47

The Bispectral Index (BIS) has become widely accepted as a measurement of hypnosis under anesthesia. It is derived from a processed electroencephalogram and computer algorithm that assigns a numerical value based on the probability of consciousness. Values ,60 correlate with a low probability of consciousness (1). We report a case wherein a patient experienced explicit recall of intraoperative events, despite a BIS of 47. Case Report A 28-yr-old, 85-kg male with a history of smoking, hypercholesterolemia, and hypertension presented to the operating room for three coronary artery bypass grafts, secondary to severe coronary artery disease with normal left ventricular function. There was no family history significant for heart disease. The patient was employed as a corrections officer and had no previous medical training or experience with cardiac surgery. He had no history of recreational drug use or alcohol abuse. His surgical history was previously negative. Monitors applied included an Aspect A-2000 BIS monitor (Aspect Medical Systems, Newton, MA). Anesthesia was induced with thiopental, 4 mg/kg, nitrous oxide, 70%, in oxygen and sevoflurane, 2‐3%, with paralysis induced by vecuronium. After endotracheal intubation, he was turned laterally, and preservative-free morphine, 5 mg/ kg, administered via a 22-gauge spinal needle at the L3-4 interspace. The patient was then returned to a supine position for the duration of surgery. During placement of the intrathecal morphine, the BIS sensor had become dislodged and was replaced after returning to the supine position. As the monitor was turned on, electrode impedances were automatically checked and within acceptable limits. Anesthesia was maintained with sevoflurane and nitrous oxide until the start of cardiopulmonary bypass (CPB), when it was changed to isoflurane in oxygen. At the conclusion of the case, the neuromuscular block from vecuronium was reversed, and the patient was awakened, tracheally extubated, and transferred to the cardiovascular intensive care unit in stable condition. He had an uneventful recovery and was discharged home on the fourth postoperative day. During his postanesthesia interview, 48 h after surgery, the patient reported that he could recall voices in the operating room, the sound of the sternal saw being tested, and could feel his chest being opened. The patient denied any pain, and did not recall anything after sternotomy. He clearly described the sound of the nitrogen-powered sternal saw to the anesthesiology resident conducting the postoperative evaluation. This was elicited spontaneously by the patient and not as a result of a specific inquiry about recall. The patient had no prior history of intraoperative recall. Review of the medical record revealed a BIS of 47 at the time of sternotomy, 35 min after induction of anesthesia. At the time of sternotomy, Fio2 was 0.26, Fin2o was 0.67, and inspired sevoflurane was 2%. The sevoflurane initially was started at 4%, and had been at 3% for most of the time before sternotomy. The patient’s heart rate and blood pressure were slowly decreasing after the induction, and the sevoflurane concentration was also slowly decreased to 2%, as noted. The vaporizer in use on the anesthesia machine had previously functioned well, and end-tidal sevoflurane was appropriately detected by a RASCAL gas-monitoring device (Ohmeda, Tewksbury, MA). Despite this, the patient was quite satisfied with his anesthetic and reported no psychological difficulties resulting from the awareness event.